Managing Anaemia in Pregnancy

Claire L J Atterbury
CNS Transfusion Medicine
 Is this important?
Is it just about reducing the amount of
components used?
 What am I going to talk about?
• Iron
• B12
• Folate
• Increasing women’s wellbeing
• Reducing midwives’ workload
• A bit about the babies.
 Iron
Increased requirements in pregnancy
Fetus - 270mg
Placenta and cord - 90mg
Delivery - 150mg
Normal loss - 280mg
(1mg per day)
RCM - 450mg
Total -1240mg
 Iron

• BUT + gain 240-480mg (no menses)

• Total loss 1240mg – 240/480 = 1000/760

Net requirement for all in 280 days 700 – 1400mg (2.5-5mg/d.)

Most women end their pregnancy low in iron but not necessarily anaemic

Therefore where are ….

• Primips?
• Multips?

Aim of Antepartum treatment - to get to 3 months post partum with normal iron
stores. It is do-able.
Patient blood management in obstetrics:
management of anaemia and haematinic
deficiencies in pregnancy and in the
post-partum period: NATA consensus
statement
M. Muñoz J. P. Peña-Rosas S. Robinson N. Milman
W. Holzgreve C. Breymann F. Goffinet J. Nizard F.
Christory C.-M. Samama J.-F. Hardy
UK guidelines on the management of iron
deficiency in pregnancy
Sue Pavord Bethan Myers Susan Robinson Shubha
Allard Jane Strong Christina Oppenheimer on behalf
of the British Committee for Standards in
Haematology
 It starts at booking………
• A careful history
– General health
– Family history
– Bleeding history – Obstetric and otherwise (menses, surgery)
– Any previous history of anaemia?
• Beliefs and wishes and fears concerning blood transfusion
• Drug history (legal and other)
• Allergies
 Investigations based on your findings
• Anaemia screen as baseline if there are concerns
– Repeat FBC
– U&E and LFT
– Clotting
– B12 ,Folate and Ferritin
– CRP
• Do a look back, if possible, to previous non pregnancy results – particularly
the MCV, MCH
• Remember to ask them to tell you if they get any infections such as a UTI,
chest infection, common cold, norovirus etc. More than one could mean
they have become deficient.
 Haemoglobin
• Anaemia = haemoglobin < 120g/l for all women (WHO)
• Haemoglobin concentration determined by:
– Red cell mass (RCM)
– Plasma volume (PV)
• True anaemia = fall in RCM
• During pregnancy:
– PV rises by 1 litre (max. at 24 – 30/40)
– RCM rises by 300ml (max. at 30/40)
– Overall fall in Hb, max at 30/40 = dilutional anaemia
(min. Hb =110g/l)
 Into the 3rd Trimester
• Look again at their blood
• Has the MCV dropped?
• Think about Iron, B12 and Folate.
• If Iron is low use a treatment dose of oral iron
• But they are on Pregaday….?
• If time is marching on (32/40+) consider IV Iron for complete
stores replacement
Adverse effects/risks of Iron deficiency in Pregnancy, Delivery
and Post partum to Mum

• Unpleasant symptoms
– Lethargy, dyspnoea, fatigue, insomnia, light headedness, dizziness and
disorientation
• Increased susceptibility to infection
• Decrease in thermoregulation
• Ante partum haemorrhage ++
• Post partum haemorrhage ++
• Delayed wound healing
• Reduced quality and quantity of Lactation or even halted
• Excessive fatigue and failure to cope
 And for the wee ones……….
• Poor uterine growth
• Decreased liquor
• Asymmetrical growth patterns
• Small for dates
• Premature delivery
• Low birth weight
• Failure to thrive (poor lactation)
• And if it continues - poor concentration and reduced scholarly
achievements

• And for the Midwife……………….??!!

 Iron Therapy Timeline in Pregnancy
The Pregnancy Time Line -
Potential for Fe Therapy in Pregnancy

100
Potential (%)

Oral Fe
Conception Birth
Venofer

1st trimester 2nd Trimeseter 3rd Trimester

0
-12 -4 4 12 18 24 32 40 48
Weeks
 Oral Iron

• Very cheap
• Get the right dose and length
of treatment.
• Slow to work but will raise
Iron stores within 1/52.
• Side effects!
• Patient and practitioner
confidence.
• Every day or every other
day?
 Intravenous
• Rapid (almost as fast as a transfusion, ~ 4-5 days).
• Can target an exact level of Iron and Hb.
• Licensed in 2nd and 3rd Trimester.
• Side effects?
– Minor and rare but can be frightening. Most gone within 30 minutes.
– Nausea (may last 24 hours)
– Facial and limb flushing
– Hypertension
– Anaphylaxis is extremely rare in the product we use (1: 800 000 doses here)
– All p[atients must be observed for 30 minutes
• Which product is available to you? Venofer, Cosmofer, Ferinject, Monofer
 Oral Iron vs Venofer in the Postpartum
(Dr Nav Bhandal, John Radcliffe, Oxford, personal communication)
13

12

11

10

5
Antepartum

Day 0

Day 5

Day 14

Day 40
Oral Iron 200mg bd for 6 wks Venofer 200mg on Day 2 and 4
 Don’t forget Folate deficiency (or B12)
• Pregnancy requires extra 200 • Diagnosis:
micro grams per day 1. Haemoglobin
2. MCV
• Increased risk of deficiency: 3. Serum folate
– Poor nutrition 4. Red cell folate
– Twins
– Haemolysis (autoimmune, viral) • Treatment
– Malaria
– Folic acid 5mg OD throughout
– Infection
pregnancy
– Drugs
– Hydroxycobalamin as per ante
natal policy
– Patients should be checked
 Blood is more dangerous than you might
think…………
Mini transplant of live cells from the donor to the
recipient including some antibodies in plasma.
What consequences may happen now?
In the future?
 Transfusion

• What component?
• Any special requirements?
– Irradiation /CMV negative?
– Antibodies?
– Childbearing age females - Kell negative (can be a
precursor to HDN – rarely)
 What if they tell you they
REALLY don’t want blood?
• Find out why.
• What do they mean by blood?
• Are there fears or questions you can explain and answer?
• Get advice from the hospital transfusion team.
• Get an anaemia management and bleeding plan into the notes.
• Inform the Consultant Obstetrician, Anaesthetist and Haematologist (I
always tell the lab too).
• Ask that they complete an Advanced Directive.
• If they are Jehovah’s Witnesses suggest they discuss what to include in the
AD with their Hospital Liaison Elder.
Case study1

• 37 yr Jehovah’s Witness – G5 P4
• Delivered at 39/40
• Hb at delivery 10.1g/dl
• Previous PPH x3
(no one though uh-oh or told anyone)
• Massive bleed
• Hb dropped to 4.5
 Plan
• Take her to Theatre – ASAP (ligation not TAH).
• Ventilate on ITU.
• Check and recheck Advance Directive.
• Give 200mg Venofer TIW
• Give 3x doses 40K Eprex
• Hb dropped to 1.9 (eek!)
• Haematologists dash off to Athens to conference
• Hold nerve (mostly by phone)
• Hb 5.6 @1 week post delivery
• Hold debriefing meeting post discharge
 What did we learn?
• Alert Consultant, Hospital Transfusion Team (HTT) and Anaesthetist at
booking if refusing blood.
• Refer to CNS Transfusion (HTT) to make a plan and communicate clearly
and widely to cover several eventualities.
• If PPH occurs out of hours call in the consultants (Obs, Haem and
Anaesthetics) even if minor to start with.
• ITU were fantastic – ask for review early if bleeding.
• Advance directives are VERY useful especially in an emotionally charged
situation.
Bleeding plan

10
 Case Study 2
• 22 year old – G3 P2
• 37/40
• Admitted to Castleacre with Norovirus
• Christmas.
• Septic
• Distressed baby crash section
• Hb 31g/l, Platelets 41 x109/l , Neutrophils 0.3 x109/l
• B12 99, Folate 1.6, CRP 280
 Then…

• 14 days as inpatient
• Septic shock – removal to ITU
• 8 units of Red cells
• 1 unit of Platelets
• IV antibiotics
• Lots of stress and anxiety for everyone……….she didn’t sue us
 Back up a bit………..
• 30.9.08 - 28 week bloods showed MCV 109 and film comment “macrocytic
anaemia. Probable B12 deficiency”

• 6.11.08 MCV 116. Hb 90 Film comment “Macrocytic picture ?Liver ?B12

/Folate deficiency.”

• 13.11.09 B12 117, Folate 0.9 (3-20) Red Cell Folate 48 (93-641)

• Patient given oral iron. Usual Midwife on AL. Patient moved house.

• 10.12.09 UTI – E-Coli

• 27.12.09 Admitted with diarrhoea. Norovirus. Baby distressed.

 Case study 3
• 36 year old Journalist
• Best friend a Transfusion Nurse Specialist (woohoo)
• Not keen on blood transfusion
• On Pregaday
• Hb 90 at 28weeks
• MCV lower than pre-pregnancy (9185)
• Asked for advice by midwife
 Plan
• Increase oral Iron to FeSO4 200mg BD from week 28
• Continue folic acid to delivery

• Delivered at 42/40
• 1400 ml bleed
• Hb at 2 days PP 100g/l
Remember - No blood needs planning (and nerve!)

• Assessment of anaemia for all patients at booking.

• Get advice and a plan from the HTT (it’s all in the planning and
preparation).
• Find out if your patient really is immovable if refusing blood.
• Blood should only be used in Obstetrics to save a life
• Advance Directives help.
• Use an appropriate product that is safe and cost effective.
THANK YOU!